B4158 prior authorization | Blue Cross Blue Shield Oklahoma

B4158, Enteral Formula For Pediatrics Nutritionally Complete With Intact Nutrients Includes Proteins Fats Carbohydrates Vitamins And Minerals May Include Fiber And/Or Iron Administered Through An Enteral Feeding Tube 100 Calories = 1 Unit, is on the Blue Cross Blue Shield Oklahoma commercial prior authorization list. Not a coverage or referral decision.

Code: B4158
Description: Enteral Formula For Pediatrics Nutritionally Complete With Intact Nutrients Includes Proteins Fats Carbohydrates Vitamins And Minerals May Include Fiber And/Or Iron Administered Through An Enteral Feeding Tube 100 Calories = 1 Unit
Source: 2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 200 Original policy

Blue Cross Blue Shield Oklahoma prior authorization

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